Anterior versus posterior approach in the treatment of chronic thoracolumbar fractures.
Chen ZW, Ding ZQ, Zhai WL, Lian KJ, Kang LQ, Guo LX, Liu H, Lin B. Orthopedics. 2012 Feb 17;35(2):e219-24.
The purpose of this study was to compare the results of anterior approach vs posterior approach in the treatment of chronic thoracolumbar fractures. A total of 36 patients with chronic thoracolumbar fractures were divided into 2 groups. Group A was treated by an anterior approach and group B was treated by a posterior approach. During the minimum 24-month follow-up period (range, 24-62 months), all patients were prospectively evaluated for clinical and radiologic outcomes. Intraoperative blood loss, operative time, operative complications, pulmonary function, Frankel scale, and American Spinal Injury Association (ASIA) motor score were used for clinical evaluation, and Cobb angle was examined for radiologic outcome.All patients in this study achieved solid fusion, with significant neurologic improvement. Operative time, perioperative blood loss, ASIA score on admission and at final follow-up, and complications of respiratory tract infection and intercostal nerve pain were not significantly different between the 2 groups (P>.05), but complications of hemopneumothorax, abdominal distension, and constipation were fewer in group B (P<.05). Postoperative pulmonary function (P<.05) and correction of posttraumatic kyphosis were better in group B (P<.05). PMID: 22310410
Prevalence of vertebral fracture in oldest old nursing home residents.
Rodondi A, Chevalley T, Rizzoli R. Osteoporos Int. 2012 Feb 1. [Epub ahead of print]
We evaluated vertebral fracture prevalence using DXA-based vertebral fracture assessment and its influence on the Fracture Risk Assessment (FRAX) tool-determined 10-year fracture probability in a cohort of oldest old nursing home residents. More than one third of the subjects had prevalent vertebral fracture and 50% osteoporosis. Probably in relation with the prevailing influence of age and medical history of fracture, adding these information into FRAX did not markedly modify fracture probability. INTRODUCTION: Oldest old nursing home residents are at very high risk of fracture. The prevalence of vertebral fracture in this specific population and its influence on fracture probability using the FRAX tool are not known. METHODS: Using a mobile DXA osteodensitometer, we studied the prevalence of vertebral fracture, as assessed by vertebral fracture assessment program, of osteoporosis and of sarcopenia in 151 nursing home residents. Ten-year fracture probability was calculated using appropriately calibrated FRAX tool. RESULTS: Vertebral fractures were detected in 36% of oldest old nursing home residents (mean age, 85.9 ± 0.6 years). The prevalence of osteoporosis and sarcopenia was 52% and 22%, respectively. Ten-year fracture probability as assessed by FRAX tool was 27% and 15% for major fracture and hip fracture, respectively. Adding BMD or VFA values did not significantly modify it. CONCLUSION: In oldest old nursing home residents, osteoporosis and vertebral fracture were frequently detected. Ten-year fracture probability appeared to be mainly determined by age and clinical risk factors obtained by medical history, rather than by BMD or vertebral fracture. PMID: 22302103
Surgical vs Nonoperative Treatment of Hadley Type IIA Odontoid Fractures.
BACKGROUND: : Type II odontoid fractures with additional chip fragments are rare in clinical practice, accounting for < 10% of all odontoid fractures. Hadley et al were the first to describe these fractures as an individual subtype (IIA). OBJECTIVE: : To analyze the outcome of patients after surgical or nonoperative treatment of Hadley type IIA odontoid fractures. METHODS: : We analyzed the records of 46 patients at an average of 64 years of age at the time of injury. Twenty-five patients underwent surgical stabilization by anterior screw fixation and were entered into study group A; 21 patients were treated nonoperatively by halo vest immobilization and included in study group B. RESULTS: : Thirty-seven patients (84%) returned to their preinjury activity level and were satisfied with their treatment. Using the Cervical Spine Outcomes Questionnaire to quantify the clinical outcome, we had an overall outcome score of 21.8. We did not find a significant difference in the overall clinical outcome between study groups. Bony fusion was achieved in 35 patients (80%). We had a nonunion rate of 13% after anterior screw fixation and a significantly higher rate of 30% after halo vest immobilization. Failure of reduction or fixation occurred in 12 patients (27%), with a significantly higher failure rate after halo vest immobilization. CONCLUSION: : Hadley type IIA odontoid fractures are inherently unstable and impede proper realignment. These fractures have a significantly increased risk for secondary loss of reduction and bony nonunion, particularly after nonoperative management. Early surgery should be considered to avoid further complications. PMID: 22343791
Added value of percutaneous vertebroplasty: effects on respiratory function.
Tanigawa N, Kariya S, Komemushi A, Nakatani M, Yagi R, Sawada S. AJR Am J Roentgenol. 2012 Jan;198(1):W51-4.
OBJECTIVE: The objective of our study was to investigate the effects of percutaneous vertebroplasty on respiratory function in patients with compression fractures caused by osteoporosis. SUBJECTS AND METHODS: Ninety-eight patients (87 women, 11 men; mean age, 74 years; age range, 60-90 years) with compression fractures of 75 thoracic (Th7-Th12) and 89 lumbar (L1-L5) vertebrae were enrolled in this study. Percentage vital capacity (VC%), percentage forced vital capacity (FVC%), and percentage forced expiratory volume in 1 second (%FEV1) were measured using a spirometer before, 1 day after, and 1 month after percutaneous vertebroplasty. The Wilcoxon signed rank test was used to evaluate whether any significant differences in VC%, FVC%, or %FEV1 values existed between before, 1 day after, and 1 month after percutaneous vertebroplasty. RESULTS: The VC% and FVC% values had improved significantly by 1 month after percutaneous vertebroplasty compared with before percutaneous vertebroplasty (p<0.01). No significant difference was noted between values before and 1 day after percutaneous vertebroplasty. Likewise, no significant difference was identified in %FEV1 before percutaneous vertebroplasty and either 1 day or 1 month after percutaneous vertebroplasty. The mean degree of improvement in VC% values after percutaneous vertebroplasty for patients with one vertebra treated, which we refer to as the "single-vertebroplasty" group, and for patients with two or more vertebrae treated, or "multiple-vertebroplasty" group, was 1.1%±7% (SD) and 6.3%±8%, respectively, representing a significant difference between groups (p=0.01). The mean VC% values before and 1 month after percutaneous vertebroplasty differed significantly (p=0.02) in the thoracic group and overlapping group. CONCLUSION: Percutaneous vertebroplasty improves restrictive ventilatory impairment, but this improvement requires approximately 1 month to occur. Greater improvement in restrictive ventilatory dysfunction was observed in patients who underwent multiple vertebroplasty procedures than those who underwent a single procedure and in patients who underwent treatment of thoracic vertebrae than those who underwent treatment of other vertebrae. PMID: 22194515
Incidence of Adjacent Segment Disease Requiring Surgery After Anterior
Cervical Diskectomy and Fusion: Estimation Using an 11-Year
Comprehensive Nationwide Database in Taiwan.
Wu JC, Liu L, Wen-Cheng H, Chen YC, Ko CC, Wu CL, Chen TJ, Cheng H, Su TP. Neurosurgery. 2012 Mar;70(3):594-601.
BACKGROUND:: The incidence of symptomatic adjacent segment disease (ASD) after anterior cervical diskectomy and fusion (ACDF) was reported as 2.9%/y in a previous cohort of 374 patients. Few other data corroborate the incidence and natural history of ASD. OBJECTIVE:: To calculate the incidence of ASD after ACDF that required secondary fusion surgery. METHODS:: The retrospective study used an 11-year nationwide database to analyze the incidences. All patients who underwent ACDF for cervical disk diseases were identified through diagnostic and procedure codes. Kaplan-Meier and Cox regression analyses were performed. RESULTS:: From 1997 to 2007, covering 241 800 725.8 person-years, 19 385 patients received ACDF and 568 had ≥ 2 ACDF operations. The incidence of secondary ACDF operations was 7.6 per 1000 person-years. At the end of the 10-year cohort, 94.4% of patients who had received 1 ACDF remained free from secondary ACDF. The average time interval between the first and second ACDF was 23.3 months. After adjustment for comorbidities and socioeconomic status, secondary ACDF operations were more likely performed on male patients (hazard ratio = 1.27; P = .008) 15 to 39 years of age (hazard ratio = 1.45; P = .009) and 40 to 59 years of age (hazard ratio =1.41, P =.002, respectively). CONCLUSION:: Repeat ACDF surgery for ASD cumulated steadily in an annual incidence of approximately 0.8%, much lower than the reported incidence of symptomatic ASD. However, at the end of this 10-year cohort, a considerable portion of patients (5.6%) received a second operation. Younger and male patients are more likely to receive such second operations. PMID: 22343790
Variations in sacral morphology and implications for iliosacral screw fixation.
Miller AN, Routt ML Jr. J Am Acad Orthop Surg. 2012 Jan;20(1):8-16.
Posterior pelvic percutaneous fixation following either closed or open reduction is a popular procedure. Knowledge of the posterior pelvic anatomy, its variations, and related imaging is critical to performing reproducibly safe surgery. The dysmorphic sacrum has several key characteristics. The upper portion of the sacrum is relatively colinear with the iliac crests on the outlet radiographic view. Other characteristics include the presence of mammillary bodies (ie, underdeveloped transverse processes) at the sacral mid-alar area, anterior upper sacral foramina that are not circular, residual upper sacral disks, an acute alar slope oriented from cranial-posterior-central to caudal-anterior-lateral on the outlet and lateral views of the sacrum, a tongue-in-groove sacroiliac joint surface visualized on CT, and cortical indentation of the anterior ala on the inlet radiographic view. The surgeon must be knowledgeable about individual patient anatomy to ensure safe iliosacral screw placement. PMID: 22207514
Percutaneous vertebral body cement augmentation for back pain related to occultosteomyelitis/diskitis.
Buttermann GR, Mullin WJ. Orthopedics. 2011 Nov 9;34(11):e788-92. doi: 10.3928/01477447-20110922-31.
Although complications related to vertebroplasty or kyphoplasty are few, we treated 2 patients with vertebroplasty or kyphoplasty for pain, presumed to be due to vertebral compression fractures, which were subsequently found to be due to occult osteomyelitis/diskitis. The onset of their infections appeared to have preceded their vertebral body augmentation procedures and was possibly due to prior interventional procedures for histories of back pain.An 86-year-old woman had had 3 prior kyphoplasty procedures for fractures at T10, T11, and L1. She reported continued severe pain, and subsequent magnetic resonance imaging was misinterpreted for another fracture at T12, resulting in her fourth kyphoplasty. She became septic and had some improvement with antibiotics, but she declined specialty care and died. A 74-year-old man with chronic back pain had recently undergone lumbar facet joint injections. Computed tomography and subsequent bone scan found uptake at both L2 and L3. Despite abnormal erythrocyte sedimentation rate and C-reactive protein level and normal radiographic vertebral height, he underwent a vertebroplasty. His pain increased, and subsequent workup found L2-3 diskitis. He recovered with antibiotics and specialty care. Similar to prior reports of spondylodiskitis, both patients had multiple medical comorbidities.This article emphasizes the need for clinical reevaluation and scrutiny in the interpretation of imaging studies, including for infection in patients with continued pain after spinal procedures. The differential diagnosis of infectious etiology is an important consideration prior to vertebral cement augmentation for presumed fragility fracture. PMID: 22049968
The Utility of Bone Cement to
Prevent Lead Migration with Minimally Invasive Placement of Spinal Cord
Stimulator Laminectomy Leads.
Connor DE Jr, Cangiano-Heath A, Brown B, Vidrine R, Battley T 3rd, Nanda A, Guthikonda B. Neurosurgery. 2012 Feb 6.
Lead migration is a significant concern with spinal cord stimulator (SCS) placement with rates ranging from 10-60%. We
describe a novel technique utilizing bone cement at the laminotomy site
to help prevent lead migration after minimally invasive placement of
laminectomy paddle leads, and present our short term results. METHODS:
A review of a prospectively maintained database identified all patients
who underwent minimally invasive placement of laminectomy leads with
use of bone cement. All procedures were performed between July 2008
and August 2010 utilizing conscious sedation and local anesthetic.
Intraoperative testing was performed to confirm good pain coverage. A
small volume of bone cement (1-3 cc) was then placed to cover the
laminectomy defect. Radiographic and clinical follow up was assessed. Forty-two
patients (mean age 58.0 yrs) underwent 42 procedures. Back pain (88.1%)
and leg pain (88.6%) were the most common presenting symptoms. No
intraoperative complications were noted. Two (4.8%) patients required
removal of their devices due to non-healing wounds. All patients were
followed for a minimum of six months and no cases of clinical or
radiographic lead migration have been seen at the time of publication. CONCLUSION:
We present a novel technique in hopes of decreasing the incidence of
lead migration after minimally invasive placement of spinal cord
stimulator laminectomy paddle leads. Our results have been promising
thus far with no cases of lead migration.
Percutaneous vertebroplasty for pathological vertebral compression fractures secondary to multiple myeloma.
Chen LH, Hsieh MK, Niu CC, Fu TS, Lai PL, Chen WJ. Arch Orthop Trauma Surg. 2012 Feb 8. [Epub ahead of print]
Vertebral compression fractures are common in multiple myeloma.
Percutaneous vertebroplasty is used to stabilize vertebral collapse and
treat the pain. The major technical drawbacks of percutaneous
vertebroplasty are the potential for neural comprise and pulmonary
embolism of cement from leakage of polymethylmethacrylate into epidural
space and perivertebral veins. We have retrospectively evaluated the
safety and complication of percutaneous vertebroplasty in the vertebral
compression fractures resulting from multiple myeloma.
From August 2003 to July 2008, we describe 24 patients withmultiple
myeloma who were treated for vertebral compression fractures with
percutaneous vertebroplasty to a total of 36 vertebrae. There were 4
male and 20 female patients with an average age of 67 (range 54-81
years). The pain symptoms were measured on a visual analog pain scale
and quality of life as measured by the physical component summary scale
of the Short Form-36 before operation and at 24 h, at 3 months and at 1
year following vertebroplasty. Radiography was reviewed for evidence of cement leakage and pulmonary complication. RESULTS:
The mean visual analog pain scale decreased from a preoperative value
of 9.0-3.8 at 24 h following operation and SF-36 score improved from
22.1 to 41.8. Of the twenty-four patients, four had cement leakage (2
leak through inferior endplate into disc, 2 leak into perivertebral
vessels). There were no intra-postoperative neurologic or pulmonary
complications. Eight patients died 2-18 months post-operatively due to multiple myeloma-related organ failure. CONCLUSIONS:
In this study, vertebroplasty significantly improved pain scores and
function and, thereby, the quality of life. There were no major
procedure-related complications in this study. Direct cytotoxic effect,
polymerization and biomechanical microfractures stabilizer of
polymethylmethacrylate play multiple roles in pain relief. In multiple
myeloma, when pathological spinal compression fractures cause
intractable pain and are unresponsive to conservative treatment,
vertebroplasty remains the best option for pain relief and is effective
in increasing quality of life. PMID: 22314399
Comparison of stability of two kinds of sacro-iliac screws in the
fixation of bilateral sacral fractures in a finite element model.
Injury. 2012 Jan 24. [Epub ahead of print] Zhao Y, Li J, Wang D, Liu Y, Tan J, Zhang S. Department of Orthopaedics, Yantai Shan Hospital, Yantai, Shandong, PR China.
compare the stability of lengthened sacro-iliac screw and sacro-iliac
screw for the treatment of bilateral vertical sacral fractures to
provide reference for clinical application. A finite element model
of Tile C pelvic ring injury (bilateral type Denis II fracture of
sacrum) was produced. (Tile and Denis are surgeons, who put forward the
classifications of pelvic ring injury and sacral fracture
respectively.) The bilateral sacral fractures were fixed with a
lengthened sacro-iliac screw and a sacro-iliac screw in seven types of
models, respectively. The translation and angular displacement of the
superior surface of the sacrum in the case of standing on both feet
were measured and compared. The stability of one lengthened
sacro-iliac screw fixation in the S1 or S2 segment is superior to that
of two bidirectional sacro-iliac screws in the same sacral segment; the
stability of one lengthened sacro-iliac screw fixation in S1 and S2
segments, respectively, is superior to that of two bidirectional
sacro-iliac screw fixation in S1 and S2 segments, respectively; the
stability of one lengthened sacro-iliac screw fixation in S1 and S2
segments, respectively, is superior to that of one lengthened
sacro-iliac screw fixation in the S1 or S2 segment; the stability of
two bidirectional sacro-iliac screw fixation in S1 and S2 segments,
respectively, is markedly superior to that of two bidirectional
sacro-iliac screw fixation in the S1 or S2 segment and is also markedly
superior to that of one sacro-iliac screw fixation in the S1 segment
and one sacro-iliac screw fixation in the S2 segment; the vertical
stability of the lengthened sacro-iliac screw or the sacro-iliac screw
fixation in S2 is superior to that of S1. The rotational stability of
the lengthened sacro-iliac screw or sacro-iliac screw fixation in S1 is
superior to that of S2. S1 and S2 lengthened sacro-iliac screws
should be used for the fixation in bilateral sacral fractures of Tile C
pelvic ring injury as far as possible and the most stable fixation is
the combination of the lengthened sacro-iliac screws of S1 and S2
segments. Even if lengthened sacro-iliac screws cannot be used due to
limited conditions, two bidirectional sacro-iliac screw fixation in S1
and S2 segments, respectively, is recommended. No matter which kind of
sacro-iliac screw is applied, the fixation combination of S1 and S2
segments is strongly recommended to maximise the stability of the
pelvic posterior ring. http://www.ncbi.nlm.nih.gov/pubmed/22281196
The systemic inflammatory response after spinal cord injury in the rat is decreased by alpha4 beta1 integrin blockade.
J Neurotrauma. 2011 Dec 9. [Epub ahead of print] Bao F, Omana V, Brown A, Weaver L. Ontario, Canada
systemic inflammatory response syndrome (SIRS) follows spinal cord
injury (SCI) and causes damage to the lungs, kidney and liver due to an
influx of inflammatory cells from the circulation. After SCI in rats,
the SIRS develops within 12 h and is sustained for at least 3 days. We
have previously shown that blockade of the CD11d/CD18 integrin reduces
inflammation-driven secondary damage to the spinal cord. This treatment
reduces the SIRS after SCI (Bao, et al, Exp.Neurol., 2011b). In another
study we found that blockade of the a4ß1 integrin limited secondary
cord damage more effectively than blockade of CD11d/CD18. Therefore, we
considered it important to assess effects of an anti-?4ß1 treatment on
the SIRS in the lung, kidney and liver after SCI. An anti-?4 antibody
was given iv at 2 h after SCI at the 4th thoracic segment and effects
on the organs were evaluated at 24 h after injury. The migration of
neutrophils into the lungs and liver was markedly reduced and all
three organs contained fewer macrophages. In the lungs and liver,
activation of oxidative enzymes MPO, iNOS, COX-2 and gp91phox,
production of free radicals, lipid peroxidation, and cell death, were
substantially and similarly reduced. Treatment effects were less robust
in the kidney. Overall, the efficacy of the anti-a4ß1 treatment did not
differ greatly from that of the anti-CD11d antibody, although details
of the results differed. The SIRS after SCI is a challenge to recovery
and attenuation of the SIRS with an anti-integrin treatment is an
important, clinically relevant finding.
The surgical treatment of Andersson lesions associated with ankylosing spondylitis.
Orthopedics. 2011 Jul 7;34(7):e302-6. Wang G, Sun J, Jiang Z, Cui X. Jinan City, Shandong Province, China
men with Andersson lesions associated with ankylosing spondylitis who
underwent surgical treatment were reviewed for this study. Eight
Andersson lesions were found in the 8 patients, and all presented as
pseudoarthrosis. Including a patient with obvious vertebral body
destruction, no obvious local kyphosis was observed. Spinal cord
compression and neural deficit were observed in 1 patient. Without
established instructions for the surgical treatment of Andersson
lesions, we alternated the surgical technique for each patient.
Therefore, 5 patients, including the patient with obvious anterior
destruction requiring reconstruction, underwent surgical treatment with
lesion curettage and anterior bone graft and fusion; 3 other patients
underwent surgical treatment without lesion curettage and anterior bone
graft. All surgeries were performed from a posterior approach.
Posterolateral autograft was supplemented to posterior instrumentation
with or without anterior bone graft.All 8 patients experienced pain
relief immediately postoperatively. No evidence of non-union was
observed on radiographs at the level of pseudoarthrosis at final
follow-up, and no neural and infectious complications were observed.
Based on these results, surgical treatment with only posterior
instrumentation supplemented by posterolateral autograft was effective
for patients with Andersson lesions without obvious vertebral body
destruction requiring reconstruction. Anterior lesion curettage and
bone graft were not necessary. Solid immobilization, achieved by
posterior instrumentation, should be the focus of the treatment of
Andersson lesions with ankylosing spondylitis.
Osteoporos Int. 2012 Jan 21. [Epub ahead of print]
is the importance of "halo" phenomenon around bone cement following
vertebral augmentation for osteoporotic compression fracture? Kim KH, Kuh SU, Park JY, Kim KS, Chin DK, Cho YE. Department
of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance
Hospital, Yonsei University College of Medicine, Seoul, Korea.
investigated the importance, risk factors, and clinical course of the
radiolucent "halo" phenomenon around bone cement following vertebral
augmentation for osteoporotic compression fracture. Preoperative
osteonecrosis and a lump cement pattern were the most important risk
factors for the peri-cement halo phenomenon, and it was associated with
vertebral recollapse. We observed a newly developed radiolucent area
around the bone cement following vertebral augmentation for
osteoporotic compression fractures. Here, we describe the importance of
the peri-cement halo phenomenon, as well as any associated risk factors
and long-term sequelae. In total, 175 patients (202 treated
vertebrae) were enrolled in this study. The treated vertebrae were
subdivided into two groups: Group A (with halo, n?=?32) and Group B
(without halo, n?=?170), and the groups were compared with respect to
multiple preoperative (age, sex, BMD, preoperative osteonecrosis) and
perioperative factors (operative approach: vertebroplasty or
kyphoplasty; cement distribution pattern; cement leakage; cement
volume), and postoperative results (VAS score, recollapse). Logistic
regression analysis was used to evaluate the relationship between the
incidence of the peri-cement halo and all of the parameters described
above. Rates of osteonecrosis were also significantly higher in
Group A than in Group B (62.5% vs. 31.2%, p?<?0.05), and kyphoplasty
(KP) was performed more frequently in Group A (43.8% vs. 17.6%,
p?<?0.05). Lump cement (93.8% vs. 30.6%, p?<?0.05) and recollapse
(78.1% vs. 24.7%, p?<?0.05) were also more common among individuals
in Group A. Logistic regression analysis also showed that preoperative
osteonecrosis (OR?=?3.679; 95% CI?=?1.677-8.073; p?=?0.001), KP
(OR?=?3.630; 95% CI?=?1.628-8.095; p?=?0.002), lump pattern
(OR?=?13.870; 95% CI?=?2.907-66.188; p?=?0.001), and vertebral
recollapse (OR?=?5.356; 95% CI?=?1.897-15.122; p?=?0.002) were
significantly associated with peri-cement halo. The peri-cement halo
was found to be associated with vertebral recollapse, this sign likely
represents a poor prognostic factor after vertebral augmentation for
osteoporotic compression fractures. http://www.ncbi.nlm.nih.gov/pubmed/22270859
Two-level motor nerve transfer for the treatment of long thoracic nerve palsy.
J Neurosurg. 2011 Oct;115(4)858-64. Epub 2011 Jun 24. Ray WZ, Pet MA, Nicoson MC, Yee A, Kahn LC, Mackinnon SE. St.Louis, Missouri
authors report a case of long thoracic nerve (LTN) palsy treated with
two-level motor nerve transfers of a pectoral fascicle of the middle
trunk, and a branch of the thoracodorsal nerve. This procedure resulted
in near-total improvement of the winged scapula deformity, and a return
of excellent shoulder function. A detailed account of the postoperative
physical therapy regimen is included, as this critical component of the
favorable result cannot be overlooked. This case establishes the
two-level motor nerve transfer as a new option for treating LTN palsy,
and demonstrates that nerve transfers should be considered in the
therapeutic algorithm of an idiopathic mononeuritis.
Modified C-7 neurotization in the treatment of brachial plexus avulsion injury.
J Neurosurg. 2011 Oct;115(4):865-9. Epub 2011 Jul 15. Lin H, Lv D, Hou C, Chen D. Shanghai, People’s Republic of China.
C-7 transfer is often used in patients with brachial plexus avulsion
injury. Traditionally, the contralateral C-7 root has only been
transferred to a single nerve, such as the median or radial nerve. In
this study, the authors aimed to evaluate the efficacy of
contralateral C-7 transfer to 2 different recipient nerves in patients
with brachial plexus avulsion injuries. Between 2004 and 2008, 10
patients with brachial plexus root avulsions underwent nerve
reconstruction using a modified C-7 neurotization technique. In this
procedure, the contralateral C-7 root was transferred via vascularized
ulnar nerve grafts to both the musculocutaneous nerve and the median nerve on the affected side. The
strength of the biceps muscles increased to M3 or M4 in 6 patients and
to M2 in 2 patients. The median nerve transfers led to regained motor
function and strength of the wrist and finger flexors with improvement
to M3 in 5 patients. Seven patients showed notable gains of sensory function (? S3). Contralateral
C-7 transfer to 2 different recipient nerves is a feasible and
efficient approach in patients with brachial plexus avulsion injuries
when the donor nerve is limited.
Modification of percutaneous vertebroplasty for painful old
osteoporotic vertebral compression fracture in the elderly: Preliminary
Injury. 2012 Jan 9. [Epub ahead of print] Shengzhong M, Dongjin W, Shiqing W, Yang S, Peng R, Wanli M, Chunzheng G. Jinan Shandong, China
study the clinical efficacy of modified percutaneous vertebroplasty
(PVP) in the treatment of painful old osteoporosis vertebral
compression fractures (OVCF). From April 2007 to October 2009, 16
cases (23 vertebrae) of symptomic old OVCF were treated with a modified
PVP. Before operation, all the patients were examined by standing
anteroposterior and lateral X-Ray and MRI. The pain level of each
patient was assessed before operation and 1 week, 6, 12 months after
the operation using visual analogue scale (VAS) and Oswestry disability
index (ODI). The middle line vertebral body height and local sagittal
Cobb's angle were also measured. Postoperative average VAS, Oswestry
disability index (ODI), the local sagittal Cobb's angle decreased from
7.8, 72.3%, and 38.2° to 3.1, 26.8%, and 21.5° respectively before and
after surgery (p<0.05). The mean midline vertebral height increased
from 13.8mm to 26.6mm before and after surgery (p<0.05). There was
no infection, nerve injury, pulmonary embolism, or death after
operation. The modified PVP can increase the space for bone cement
filling and is good for the restoration of vertebral body height. It is
an optimal procedure for the treatment of painful old OVCF.
improves pain-associated depression, somatic anxiety, and mental
well-being in patients with herniated lumbar disc.
Neurosurgery. 2012 Feb;70(2):306-11. Lebow R, Parker SL, Adogwa O, Reig A, Cheng J, Bydon A, McGirt MJ. Department
of Neurosurgery, Vanderbilt University Medical Center, Nashville,
Tennessee Department of Neurosurgery, The Johns Hopkins Hospital,
Emotional distress and depression are
common psychological disturbances associated with low-back and leg
pain. The effects of lumbar discectomy on pain, disability, and
physical quality of life are well described. The effects of discectomy
on emotional distress and mental well-being are less well understood. To
assess the effect of microdiscectomy on depression, somatization, and
mental well-being in patients with herniated lumbar discs. Patients
undergoing surgical discectomy for single-level, herniated lumbar disc
were prospectively evaluated preoperatively, and at 6 weeks and 3, 6,
and 12 months postoperatively. Back and leg pain, depression, somatic
perception, and mental well-being were assessed. One hundred
patients were enrolled. All were available for 1-year follow-up.
Preoperatively, the visual analog scale for low-back pain (BP-VAS),
visual analog scale for leg pain (LP-VAS), Zung Self-Rating Depression
Scale (ZUNG), Modified Somatic Perception Questionnaire (MSPQ), and
Medical Outcomes Short Form-36 mental component summary scale
(SF-36-MCS) were 6.3 ± 2.5, 6.3 ± 2.5, 19 ± 11, 9 ± 7, and 4 ± 14.
BP-VAS and LP-VAS significantly improved by 6 weeks. Significant
improvement in SF-36-MCS was observed by 6 weeks postoperatively,
improvement in MSPQ score was observed 3 months postoperatively, and
improvement in the ZUNG depression score was observed 12 months
postoperatively. No statistical difference occurred during the
remainder of follow-up for any outcome measured once improvement
reached statistical significance. Eighteen patients were somatized
preoperatively, 67% of which were nonsomatized 1 year postoperatively.
Ten patients were clinically depressed preoperatively, 70% of which
were nondepressed 1 year postoperatively. Improvement in SF-36-MCS,
ZUNG, and MSPQ correlated (P < .001) with improvement in BP-VAS and
LP-VAS. The majority of patients somatized or depressed
preoperatively returned to good mental well-being postoperatively.
Improvement in pain and overall mental well-being was seen immediately
after discectomy. Improvement in somatic anxiety and depression
occurred months later. Microdiscectomy significantly improves
pain-associated depression, somatic anxiety, and mental well-being in
patients with herniated lumbar disc. http://www.ncbi.nlm.nih.gov/pubmed/22251975
Long-Term Results of Spinal Cord Injury Therapy using Mesenchymal Stem Cells Derived from Bone Marrow in Humans.
Neurosurgery. 2011 Nov 29. [Epub ahead of print] Park JH, Kim DY, Sung IY, Choi GH, Jeon MH, Kim KK, Jeon SR. Seoul
the transplantation of mesenchymal stem cells (MSCs) after spinal cord
injury (SCI) has shown promising results in animals, less is known
about the effects of autologous MSCs in human SCI. To describe the
long-term results of ten patients who underwent intramedullary direct
MSCs transplantation into injured spinal cords. Autologous MSCs were
harvested from the iliac bone of each patient and expanded by culturing
for 4 weeks. MSCs (8 × 10) were directly injected into the spinal cord,
and 4 × 10 cells were injected into the intradural space of 10 patients
with ASIA A or B caused by traumatic cervical SCI. After 4 and 8 weeks,
an additional 5 × 10 MSCs were injected into each patient through
lumbar tapping. Outcome assessments included changes in motor power
grade of the extremities, magnetic resonance imaging (MRI), and
electrophysiological recordings. Although six of the ten patients
showed motor power improvement of the upper extremities in six months
follow-up, three showed gradual improvements in activities of daily
living (ADL), and changes of MRI such as decreases of cavity size and
the appearance of fiber-like low signal-intensity streaks. They also
showed electrophysiological improvement. All ten patients did not
experience any permanent complication associated with MSCs
transplantation. Three of the 10 patients with SCI who were directly
injected with autologous MSCs showed improvement in motor power of
upper extremities and in ADL, as well as significant MRI and
electrophysiological changes during long-term follow-up.
Air in the Spinal Disc With Dissecting into Psoas Muscle After Trauma
86-year-old woman was brought to our emergency department with
persistent pain in the upper region of the abdomen after a fall in
which she hit her left buttock and flank 3 months previously. Local
tenderness of the left flank was the only meaningful physical sign, and
her vital signs were stable without fever. Laboratory examinations
revealed a normal white blood cell count of 9,200/µL, with 81.3%
neutrophils and a C-reactive protein level 1.66 mg/dL.
Contrast-enhanced computed tomography of the abdomen revealed several
bubbles of gas in the disc at L4–L5 and L3–L4 with dissection into the
left psoas muscle (Fig. 1). Neither diverticulitis nor perforation of
the gastrointestinal tract was identified. However, continuous bowel
loop dilatation over the pelvis was identified on computed tomography
findings. After observation and conservative treatment, the patient's
symptoms improved, and there was no progression of peritoneal signs.
The patient was ultimately discharged with some laxative drugs and was
unremarkable at the regular follow-up. The finding of free air in
the peritoneal or retroperitoneal region of the abdomen often indicates
life-threatening conditions, such as perforation of the
gastrointestinal tract. In the absence of perforation of the
gastrointestinal tract, several other conditions may be associated with
free air, such as bronchial asthma, mechanical ventilation, or blast
injury. In previous reports, the relationship between air bubbles in
the spinal disc and pneumoretroperitoneum after trauma was not
described. We describe a case of compression fracture of the lumbar
spine with air entering the psoas muscle after blunt trauma. It was not
difficult to hypothesize that the air was able to dissect from the
adjacent anatomy and pass through a tear of ligament or fascia.
Furthermore, on the basis of that proposed mechanism, we successfully
avoided an invasive procedure in the presence of noticeable
New laboratory tools in the assessment of bone quality.
Osteoporos Int. 2011 Aug;22(8):2225-40. Epub 2011 Feb 24. Chappard D, Baslé MF, Legrand E, Audran M. Angers, France.
quality is a complex set of intricated and interdependent factors that
influence bone strength. A number of methods have emerged to measure
bone quality, taking into account the organic or the mineral phase of
the bone matrix, in the laboratory. Bone quality is a complex set of
different factors that are interdependent. The bone matrix organization
can be described at five different levels of anatomical organization:
nature (organic and mineral), texture (woven or lamellar), structure
(osteons in the cortices and arch-like packets in trabecular bone),
microarchitecture, and macroarchitecture. Any change in one of these
levels can alter bone quality. An altered bone remodeling can affect
bone quality by influencing one or more of these factors. We have
reviewed here the main methods that can be used in the laboratory to
explore bone quality on bone samples. Bone remodeling can be evaluated
by histomorphometry; microarchitecture is explored in 2D on
histological sections and in 3D by microCT or synchrotron.
Microradiography and scanning electron microscopy in the backscattered
electron mode can measure the mineral distribution; Raman and
Fourier-transformed infra-red spectroscopy and imaging can
simultaneously explore the organic and mineral phase of the matrix on
multispectral images; scanning acoustic microscopy and nanoindentation
provide biomechanical information on individual trabeculae. Finally,
some histological methods (polarization, surface staining,
fluorescence, osteocyte staining) may also be of interest in the
understanding of quality as a component of bone fragility. A growing
number of laboratory techniques are now available. Some of them have
been described many years ago and can find a new youth; others having
benefited from improvements in physical and computer techniques are now
A Biomechanical Comparison
of A Novel Thoracic Screw Fixation Method: Transarticular Screw
Fixation versus Traditional Pedicle Screw Fixation.
Neurosurgery. 2011 Mar 24. [Epub ahead of print] Yu Y, Xie N, Song S, Zhang W, Guo Q, Ni B, Luo J. Shanghai
screw fixation is used in the upper cervical and lumbar spine to
achieve posterior spinal stability, and its biomechanical performance
is proven to be similar to that of pedicle screw fixation. However, few
studies have reported the use of transarticular screw fixation in the
upper thoracic spine. To biomechanically compare transarticular screws with pedicle screws in short-term cyclic loading in the upper thoracic spine. Eight
fresh human cadaveric spine specimens (T1-T3) were harvested and tested
for six cycles in flexion, extension, lateral bending and torsion in
their intact condition. Each specimen was then destabilized and
restabilized with three fixation methods: the pedicle screw/rod
construct, the transarticular screw/rod construct, and transarticular
screws alone. The instrumented specimens were retested using the same
protocol. All fixation systems reduced the range of motion
significantly with respect to flexion, extension, lateral bending and
axial rotation (P<0.01). However, no significant difference was
observed between the three instrumented groups. This biomechanical
study demonstrates in vitro that transarticular screws and pedicle
screws have statistically similar biomechanical stability in a
non-corpectomy model. Posterior transarticular screws may afford an
alternative for internal fixation in the upper thoracic spine.
Combined posteroanterior fusion versus transforaminal lumbar interbody fusion (TLIF) in thoracolumbar burst fractures.
Injury. 2012 Jan 6. [Epub ahead of print] Schmid R, Lindtner RA, Lill M, Blauth M, Krappinger D. Innsbruck, Austria.
optimal treatment strategy for burst fractures of the thoracolumbar
junction is discussed controversially in the literature. Whilst 360°
fusion has shown to result in better radiological outcome, recent
studies have failed to show its superiority concerning clinical
outcome. The morbidity associated with the additional anterior approach
may account for these findings. The aim of this prospective
observational study was therefore to compare two different techniques
for 360° fusion in thoracolumbar burst fractures using either
thoracoscopy or a transforaminal approach (transforaminal lumbar
interbody fusion (TLIF)) to support the anterior column. Posterior
reduction and short-segmental fixation using angular stable pedicle
screw systems were performed in all patients as a first step.
Monocortical strut grafts were used for the anterior support in the
TLIF group, whilst tricortical grafts or titanium vertebral body
replacing implants of adjustable height were used in the combined
posteroanterior group. At final follow-up, the radiological outcome was
assessed by performing X-rays in a standing position. The clinical
outcome was measured using five validated outcome scores. The morbidity
associated with the approaches and the donor site was assessed as well. There
were 21 patients in the TLIF group and 14 patients in the
posteroanterior group included. The postoperative loss of correction
was higher in the TLIF group (4.9°±8.3° versus 3.4°±6.4°, p>0.05).
There were no significant differences regarding the outcome scores
between the two groups. There were no differences in terms of return to
employment, leisure activities and back function either. More patients
suffered from donor-site morbidity in the TLIF group, whilst the
morbidity associated with the surgical approach was higher in the
posteroanterior group. The smaller donor-site morbidity in the
posteroanterior group is counterbalanced by an additional morbidity
associated with the anterior approach resulting in similar clinical
outcome. Mastering both techniques will allow the spine surgeon to be
more flexible in specific situations, for example, in patients with
neurological deficits or severe concomitant thoracic trauma.
Cost-effectiveness of Denosumab for the treatment of
Osteoporos Int. 2011
Mar;22(3):967-82. Jönsson B, Ström O, Eisman JA, Papaioannou
A, Siris ES, Tosteson A, Kanis JA.
et al. from Stockholm reports that Denosumab is a cost-effective
alternative to oral osteoporosis treatments, particularly for patients
at high risk of fracture and low expected adherence to oral treatments. Link: http://www.ncbi.nlm.nih.gov/pubmed/20936401
Direct Lateral Approach to Pathology at the Craniocervical Junction: A Technical Note.
Neurosurgery. 2011 Nov 8 Abdullah KG, Schlenk RS, Krishnaney A, Steinmetz MP, Benzel EC, Mroz TE.
Abdullah et al. from Cleveland report a direct lateral approach to the craniocervical junction. Approaches
to the foramen magnum and upper cervical spine traditionally include
posterior midline, far lateral, and endoscopic endonasal approaches.
The far lateral approach is a well-established technique for the
removal of pathology ventrolateral to the brainstem and the
craniocervical junction, but may be too extensive for lesions limited
to areas far from the midline. We employed an approach directly overlying ventral or lateral pathology. Two cases are presented in which the direct lateral approach followed by an occipitocervical fusion were successfully performed. This
approach can be considered for patients in whom a ventral decompression
is necessary but an endoscopic endonasal approach is undesirable, or
when a ventral, lateral, and ventrolateral resection of tumor, pannus,
or infection is required. Link: http://www.ncbi.nlm.nih.gov/pubmed/22072127
Development and validation of a disease model for postmenopausal osteoporosis.
Osteoporos Int. 2011 Mar;22(3):771-80. Epub 2010 Aug 11. Gauthier A, Kanis JA, Martin M, Compston J, Borgström F, Cooper C, McCloskey E; Committee of Scientific Advisors, International Osteoporosis Foundation.
article describes the development of a model for postmenopausal
osteoporosis (PMO) based on Swedish data that is easily adaptable to
other countries. The aims of the study were to develop and validate
a model to describe the current/future burden of PMO in different
national settings. For validation purposes, the model was developed
using Swedish data and provides estimates from 1990. For each year of
the study, the "incident cohort" (women experiencing a first
osteoporotic fracture) was identified and run through a Markov model
using 1-year cycles until 2020. Health states were based on the number
of fractures and death. Fracture by site (hip, vertebral, and non-hip
non-vertebral) was tracked for each health state. Transition
probabilities reflected site-specific risk of death and subsequent
fractures. Bone mineral density (BMD) was included as a model output;
model inputs included population size and life tables from 1970 to
2020, incidence of fracture, relative risk of subsequent fractures
based on prior fracture, relative risk of death following a fracture by
site, and BMD by age (mean and standard deviation). Model
predictions averaged across age groups estimated the incidence of hip,
vertebral, and other osteoporotic fractures within a 5% margin of error
versus published data. In Sweden, the number of osteoporotic fractures
is expected to rise by 11.5% between 2009 and 2020, with a shift
towards more vertebral fractures and multiple fractures. The current
PMO disease model is easily adaptable to other countries, providing a
consistent measure of present and future burden of PMO in different
settings. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/20700580 Full text: http://www.springerlink.com/content/kk50v7721p12637j/
prospective, randomized trial comparing expansile cervical laminoplasty
and cervical laminectomy and fusion for multilevel cervical myelopathy.
Neurosurgery. 2012 Feb;70(2):264-77. Manzano GR, Casella G, Wang MY, Vanni S, Levi AD. Department
of Neurological Surgery and The Miami Project to Cure Paralysis,
University of Miami Miller School of Medicine, Miami, Florida.
Controversy exists as to the best posterior operative procedure to treat multilevel compressive cervical spondylotic myelopathy. To
determine clinical, radiological, and patient satisfaction outcomes
between expansile cervical laminoplasty (ECL) and cervical laminectomy
and fusion (CLF). We performed a prospective, randomized study of
ECL vs CLF in patients suffering from cervical spondylotic myelopathy.
End points included the Short Form-36, Neck Disability Index, Visual
Analog Scale, modified Japanese Orthopedic Association score, Nurick
score, and radiographic measures. A survey of academic North
American spine surgeons (n = 30) demonstrated that CLF is the most
commonly used (70%) posterior procedure to treat multilevel spondylotic
cervical myelopathy. A total of 16 patients were randomized: 7 to CLF
and 9 to ECL. Both groups showed improvements in their Nurick grade and
Japanese Orthopedic Association score postoperatively, but only the
improvement in the Nurick grade for the ECL group was statistically
significant (P < .05). The cervical range of motion between C2 and
C7 was reduced by 75% in the CLF group and by only 20% in the ECL group
in a comparison of preoperative and postoperative range of motion. The
overall increase in canal area was significantly (P < .001) greater
in the CLF group, but there was a suggestion that the adjacent level
was more narrowed in the CLF group in as little as 1 year
postoperatively. In many respects, ECL compares favorably to CLF.
Although the patient numbers were small, there were significant
improvements in pain measures in the ECL group while still maintaining
range of motion. Restoration of spinal canal area was superior in the
CLF group. http://www.ncbi.nlm.nih.gov/pubmed/22251974